Phone *
Email *
Number of Years at Current Address *
If Less Than 3 Years, List Prior Address
Number of Owners * 1 2
Gender - Insured Person 1 Male Female
Marital Status - Insured Person 1 * Single Married Domestic Partner Separated Divorced Widowed
Occupation - Insured Person 1
Level of Education - Insured Person 1 Less Than High School High School Some College Community or Junior College Bachelor's Degree Master's Degree PhD Law Degree Medical Degree
Are You a AAA Member? - Insured Person 1 Yes No
Are You an AARP Member? - Insured Person 1 Yes No
Gender - Insured Person 2 Male Female
Marital Status - Insured Person 2 Single Married Domestic Partner Separated Divorced Widowed
Social Security Number - Insured Person 2
Occupation - Insured Person 2
Level of Education - Insured Person 2 Less Than High School High School Some College Community or Junior College Bachelor's Degree Master's Degree PhD Law Degree Medical Degree
Are You a AAA Member? - Insured Person 2 Yes No
Are You an AARP Member? - Insured Person 2 Yes No
Do You Currently Have Insurance? * Yes No
If Yes, Who is the Current Carrier?
How Long Have You Been With This Company? 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12+ Years
Prior Coverage Amount On Dwelling? *
Prior Coverage Amount on Other Structures
Prior Coverage Amount On Personal Property?
Prior Coverage Amount On Loss or Use?
Prior Liability Limit $100,000 $200,000 $300,000 $400,000 $500,000
Prior Medical Payment Limit $1,000 $2,000 $5,000
Deductible * $500 $1,000 $1,500 $2,000 $2,500 $5,000
Wind/Hail Deductible * $1,000 $1,500 $2,000 $2,500 $5,000 1% 2%
Do You Have Coverage for Earthquake? Yes No
Year Built *
Total Square Footage *
Type of Home * 1 Story 2 Stories 1.5 Stories Bi-Level Tri-Level
Construction Type * Masonry Veneer Frame Vinyl Siding Log Other
How Many Acres?
Any Mortgage? * Yes No
Number of Full Bathrooms and Half Bathrooms *
Basement * Yes No
Sunken or Walkout Basement? Sunken Walkout
Is the Basement Finished? * Yes No
If so, What Percent is Finished? 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Heat Type * None Gas Oil Electric Geo Thermal
Wood Burning Stove? * Yes No
Central Air Conditioning? * Yes No
Complete Update to Wiring? * Yes No
If Yes, What Year?
Complete Update to Heating? * Yes No
If Yes, What Year?
Complete Update to Roofing? * Yes No
If Yes, What Year?
Complete Update to Plumbing? * Yes No
If Yes, What Year?
What Type of Roof? * Asphalt/Composition Shingles Metal Other
If Shingles, What is the Warranty? 0 - 20 Years 21 - 35 Years 36+ Years Unknown
Garage/Car Port? * None Garage Car Port
Garage/Car Port Size 1 Car 2 Car 3 Car
Swimming Pool? * None Above Ground In Ground
If There is a Swimming Pool, is it Enclosed With a Fence and a Locked Gate? Yes No
If There is a Swimming Pool, Does it Have an Elevated Diving Board (More Than 1 Step)? Yes No
Trampoline? * Yes No
If Yes, is the Trampoline Enclosed in a Fence, Locked Gate, and surrounding net? Yes No
Any Other Structures on Property? If so, Describe
Are There Any Pets With Bite History or any Exotic, Undomesticated, or Vicious Animals On The Premises? * Yes No
Any Dogs? * Yes No
If Yes, is the Dog One of the Following Breeds? Rottweiler - Full Breed Rottweiler - Part Breed Doberman - Full Breed Doberman - Part Breed Pit Bull (All Variants) - Full Breed Pit Bull (All Variants) - Part Breed Akita - Full Breed Akita - Part Breed Husky/Malamute - Full Breed Husky/Malamute - Part Breed Chow - Full Breed Chow - Part Breed German Shepherd - Full Breed German Shepherd - Part Breed Presa Canarios - Full Breed Presa Canarios - Part Breed Great Dane - Full Breed Great Dane - Part Breed No
Are There any Business Pursuits Being Conducted on the Premise? * Yes No
Smoke Detectors? * Yes No
What Kind of Alarm Do You Have? * None Local Fire Local Burglary Local Fire and Burglary Central Fire Central Burglary Central Fire and Burglary
Is Your Residence Located 5 Miles or Less From the Primary Responding Fire Department? * Yes No
Is there a fire hydrant within 1000 feet? * Yes No
Who is the Primary Responding Fire Department?
Is the Residence a New Purchase? * Yes No
What's The Purchase Price?
Any Losses or Claims in the Last 5 Years? * Yes No
If Yes, Please List the Dates and a Brief Explanation of Each Claim or Loss
